A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?
Command hallucinations.
Impaired memory.
Inappropriate speech patterns.
Rapid mood swings.
The Correct Answer is A
Choice A rationale:
Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.
Choice B rationale:
Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.
Choice C rationale:
Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.
Choice D rationale:
Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"I'll take my medicine at bedtime because it will make me drowsy.”. This statement is not accurate and indicates a misunderstanding of the medication's effects. Methylphenidate, used to treat ADHD, is a stimulant medication and is not expected to cause drowsiness. Taking it at bedtime could interfere with the client's ability to sleep.
Choice B rationale:
"I need to tell my doctor if I start gaining weight.”. While it is important to report changes in weight to the healthcare provider, this statement does not indicate an accurate understanding of the medication's effects. Weight gain is not a typical side effect of methylphenidate, and this statement does not address the medication's primary purpose.
Choice C rationale:
"This medicine will help me relax and feel less anxious.”. This statement is incorrect as methylphenidate is not an anxiolytic medication. It is used to increase focus and reduce hyperactivity in individuals with ADHD. While some clients may experience a sense of calm as a result of improved focus, the primary purpose of the medication is not to reduce anxiety.
Choice D rationale:
"I know that I will be able to think more clearly now.”. This statement reflects an accurate understanding of the medication's effects. Methylphenidate is a central nervous system stimulant that can help individuals with ADHD improve their focus, attention, and cognitive function. Enhanced clarity of thought is one of the intended therapeutic effects of this medication. .
Correct Answer is A
Explanation
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel? The correct answer is choice A. Assist the client to ambulate for the first time following the procedure.
Choice A rationale:
Delegating the task of assisting the client to ambulate for the first time after electroconvulsive therapy (ECT) is appropriate. ECT can cause temporary disorientation and muscle weakness in clients. The client may need physical assistance to prevent falls and ensure their safety. Assistive personnel, under the nurse's supervision, can help the client stand, walk, and ensure their stability during this critical time.
Choice B rationale:
Witnessing the client's signature on the consent for the procedure is a critical nursing responsibility and cannot be delegated. This task ensures that the client has provided informed consent for the procedure, and it requires a licensed healthcare provider to verify the client's understanding and agreement.
Choice C rationale:
Giving the client atropine 30 minutes before the procedure involves administering a medication, which is a nursing responsibility. Atropine is used to reduce excessive salivation and bronchial secretions associated with ECT, and the administration of medication should be carried out by a licensed nurse.
Choice D rationale:
Checking the client's condition after the procedure is also a nursing responsibility. After ECT, clients may experience postictal confusion, disorientation, or temporary memory loss. The nurse must assess the client's vital signs, level of consciousness, and overall condition to ensure a safe recovery. This task requires nursing judgment and cannot be delegated to assistive personnel.
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